49 Bath Road

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders promoted a positive learning culture that supported reflection, openness and continuous improvement. They welcomed feedback and external scrutiny and used this to review practice and strengthen care delivery.

Families said staff were open and transparent when things went wrong and took time to explain what had happened and the actions taken to reduce future risk. One relative said, “If they make a mistake, they let me know and explain what is being put in place, so it doesn’t happen again,” demonstrating an open and honest approach.

External professionals confirmed that leaders were reflective and improvement focused. A behaviour analyst described leadership as “open to feedback and motivated towards ongoing improvement,” particularly in strengthening proactive PBS.

Learning from incidents, professional input and feedback was used to drive improvements in practice, helping to strengthen staff understanding, embed consistent approaches and improve outcomes for people.

A culture of openness, reflection and continuous learning supported safe care and ongoing improvement across the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff planned and delivered transitions in a consistently well‑organised, person‑centred way. They clearly communicated plans, which supported continuity of care and reduced anxiety. Staff prepared people for planned moves, community activities and holidays using social stories and easy‑read information. Professionals confirmed staff planned and communicated transitions well, which supported emotional safety and positive outcomes.

The service worked proactively to support people moving between services. Staff developed staged transition plans based on each person’s strengths, skills and preferences to build confidence and independence. They co‑produced plans with people and those important to them. Plans included visits to the service, shared meals, meetings with staff and other people, and access to local community groups and activities that reflected individual interests. This approach helped people become familiar with their new environment and build relationships before moving.

Records showed some people felt anxious or distressed when moving or adapting to new routines. In response, managers maintained consistent staffing and familiar routines to reduce distress and support emotional wellbeing.

Staff used clear shift plans with defined roles, which ensured consistent care delivery throughout the day. External commissioners said they placed people at the service because of positive outcomes, which demonstrated confidence in the service’s transition planning and delivery.

This approach supported safe, well‑planned transitions and reduced anxiety for people during periods of change.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had completed safeguarding training and demonstrated strong safeguarding practice and acted promptly to protect people from harm. They understood risks, recognised signs of abuse and reported and escalated concerns appropriately. The service provided accessible safeguarding information, including easy-read materials, which helped people understand abuse, their rights and how to raise concerns.

Staff felt confident to speak up and leaders responded quickly to concerns. A staff member told us, “I have had to report concerns before. I make sure the person is safe and comfortable first, that’s the most important thing.” Staff also felt listened to and valued, with one stating, “[Managers] take us very seriously, I know they will listen to what I have to say.”

External professionals described the service as open, responsive and proactive in identifying risks. Staff knew people well and identified early signs of deterioration. Professionals said staff had a strong understanding of individuals, including communication styles and cultural or religious needs, which supported timely intervention. The service worked collaboratively with partners and sought advice promptly when risks emerged.

Safeguarding aligned with behaviour support. Staff used positive behaviour support approaches and reviewed incidents to reduce future risk. Leaders analysed records to identify learning and improve practice.

These safeguarding arrangements protected people from abuse and avoidable harm, demonstrating how the service managed risks to keep people safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were supported to manage risks in ways that promoted choice, independence and meaningful lives. Staff worked in partnership with people, families and advocates to enable activities safely rather than restrict them. Individual risk assessments supported people to go on holidays, access the community and maintain family relationships, including where behaviours could place themselves or others at risk.

Staff implemented PBS plans for people who experienced distress and consistently followed guidance in practice. They provided one-to-one support where required and collected behavioural data, which a team leader reviewed to identify trends and support learning. Fire evacuation plans reflected individual risks and included arrangements for increased staffing where there was a risk of aggression.

Staff adjusted environments and support to reduce sensory overload and emotional distress, helping people remain safe while maintaining independence. This approach strengthened people’s confidence, enabled continued access to preferred activities and relationships, and reduced the likelihood of avoidable restrictions.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff provided a safe, well‑maintained and person‑centred environment that met people’s needs and preferences. They kept the purpose‑built home clean and free from malodours. Each person had a private bedroom with an en suite and access to a larger bathroom with safety features. Staff used spacious communal areas, a sensory room and an activity room to support both privacy and social interaction.

Staff supported people to use outdoor spaces, including a large garden and a smaller courtyard with seating and equipment such as trampolines and swing chairs. The home reflected a domestic setting, and people personalised their own rooms within the neutral décor.

Staff adapted the environment to meet people’s needs where possible, including adjustments to reduce sensory distress. For example, they removed cupboard handles to reduce the risk of injury linked to self‑injurious behaviour.

Staff managed environmental risks effectively. They locked the kitchen in line with individual risk assessments and used additional controls, such as secure knife storage, while maintaining access with staff support. Staff kept people safe through maintained fire equipment, clear evacuation signage and detailed Personal Emergency Evacuation Plans (PEEPs), including accessible information to support people to understand emergency procedures.

Leaders carried out regular safety checks and maintenance. Staff used window restrictors, stored cleaning products securely and restricted access to high‑risk areas to reduce risks.

These arrangements enabled people to live safely while maintaining choice, independence and access to shared spaces.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Safe, consistent staffing arrangements ensured staff met people’s needs. Sufficient staffing levels, including 1-to-1 support for people with complex health needs, enabled timely responses and reduced risks, such as prompt intervention in line with one person’s epilepsy care plan. Flexible deployment supported a reduction in support for some people as their independence increased.

Leaders maintained a stable workforce and ensured continuity by using internal bank staff rather than agency staff. Managers provided additional support when needed, and rotas reflected people’s preferences by matching individuals with workers who knew them well.

Leaders carried out thorough recruitment checks to confirm suitability. Training and experience enabled the team to support people with complex needs confidently. One member of staff said, “I always feel safe at work as I and my colleagues know what to do, even in the face of the most challenging situations.” Another said, “We have to keep learning and adapting. We grow and develop along with them.” Regular supervision supported ongoing development.

Professionals described the approach as “collaborative and proactive” and confirmed workers “quickly reach out” when risks increased. This supported safe, consistent care and positive outcomes for people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Effective infection prevention and control systems reduced the risk of infection and protected people’s health and wellbeing. Established cleaning routines ensured staff regularly cleaned communal areas, bedrooms and self‑contained flats using appropriate products. Managers monitored completion through signed records and routine checks to confirm staff carried out tasks as required.

Leaders ensured staff completed infection prevention and control training and understood their responsibilities. Staff followed agreed cleaning procedures, maintained good hygiene practices and responded appropriately to spillages. Supervision and ongoing monitoring reinforced these expectations.

Managers implemented deep cleaning schedules and maintained records showing staff thoroughly cleaned bedrooms, bathrooms and shared areas, with shift leaders confirming completion. Staff reported any cleanliness or maintenance concerns promptly so leaders could address them without delay.

These arrangements supported consistent hygiene standards, minimised risks and protected people’s health and wellbeing.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely and people received them as intended. Medicines were stored securely at appropriate temperatures, with sufficient stock to meet people’s needs. Staff administered medicines as prescribed and there were enough trained staff on duty. Staff demonstrated good knowledge and responded openly to questions, supporting safe practice.

Care records included person‑centred medicines plans with clear guidance on administration, including ‘when required’ protocols. Medicines were reviewed regularly with relevant professionals, and staff worked closely with health services to support coordinated care.

Where medicines were administered covertly, appropriate Mental Capacity Act assessments were completed and best interests decisions were clearly recorded. These involved relevant professionals and followed agreed processes to ensure medicines were given safely and in the person’s best interests. Covert medication is the administration of medicines in a disguised format, such as in food or drink, without the person’s knowledge.

Medicines were not used to control behaviour. Staff applied least restrictive approaches and supported people using positive behaviour strategies in line with stopping over‑medication of people with a learning disability, autism or both principles.

Systems supported safe medicines management, including regular audits, incident reporting and review. Staff received training and were assessed as competent, including for specialist health needs.

However, we found that recording of medicines taken out for social leave was not always accurate. Staff did not always seek pharmacist advice on the suitability of crushing medicines for covert administration. This meant there was a risk medicines were not always managed in line with best practice. The provider took action following the inspection to address this.

Medicines were managed safely, and improvements taken following the inspection strengthened recording and oversight, helping to protect people’s health, rights and wellbeing.